Q. Can you please elaborate on the Depakote rapid stabilization protocol giving time frame, dosing, etc.?

A.
The protocol you may have in mind is the so-called oral loading strategy for divalproex, developed by Keck, McElroy and others (see, e.g., Hirschfeld et al, J Clin Psychiatry Dec. 1999). Basically, this involves giving the patient a dose of 30 mg/kg/day of divalproex [Depakote] on days 1 and 2, followed by 20 mg/kg/day on days 3-10. This regimen typically produces a valproate blood level above 50 mcg/mL by day 3 of the protocol, in about 85% of patients.

The study cited found no difference in the frequencies or types of adverse effects in patients treated with oral loading vs. usual dosing strategies; however, in my experience, elderly and/or medically ill bipolar patients may be less tolerant of such a rapid dosing schedule.

You may also be interested in another method of rapid stabilization using valproate. In Europe, there are reports of good results using intravenous valproate loading, for acute mania. One report found that a patient who had previously been resistant to oral loading did respond to IV treatment (Grunze et al, J Clin Psychopharmacol Aug. 1999, pp. 303-9.